Quality Rounds
Subtle Reminder
By Scott D. Smith
Sending interpreters on hospital rounds increases their visibility and the likelihood that patients and staff will make use of their expertise.
The old saw “out of sight, out of mind” appears to hold true for language interpreters: If they’re not visible in the hospital, neither patients nor providers think to use them.
That was one lesson staff at Regions Hospital in St. Paul and Hennepin County Medical Center (HCMC) in Minneapolis learned while taking part in a Robert Wood Johnson Foundation project aimed at assessing the quality of interpreter services and their effect on care and piloting improvements.
The hospitals were among 10 in the United States chosen to join a learning collaborative called Speaking Together that started in November of 2006 and ends this month. All of the hospitals have a high percentage of patients who either don’t speak English or have modest English proficiency. Each has an extensive language services department as well.
During Speaking Together’s 16-month run, participating hospitals assessed their performance on five measures: whether staff asked the patient about and documented his or her preferred language, how often patients received intake and discharge instructions from a bilingual provider or interpreter, whether patients waited more than 15 minutes for an interpreter, how much time the interpreter spent interpreting during an appointment, and how much time the interpreter spent waiting for the provider. The hospitals were also asked to select clinical measures to study (see “Interpreter Services and Clinical Outcomes”).
Discovering Deficiencies
The learning collaborative provided an opportunity for participants to discuss problems and share solutions. Although the final report on the project isn’t scheduled to be released until later this year, the two Minnesota hospitals have already begun applying what they learned.
Regions concentrated its efforts on the use of interpreter services in its behavioral health unit and two of its medical units. HCMC focused on its provision of language services to Somali patients in its psychiatric unit and to Spanish-speaking patients in its diabetes clinic.
Neither hospital had tracked how and when interpreter services were actually provided. To collect this data, the hospitals’ IT departments added fields to their electronic medical record systems. Regions had its measurement system up and running by January 2007. HCMC started collecting data in June.
Among other things, the hospitals discovered that they were doing poorly on the study’s most significant measure: having an interpreter present during admission and discharge—times during which critical information is conveyed.
Education and Exposure
Sidney Van Dyke, director of interpreter services at Regions, says their staff had often used family members to interpret during admission and discharge rather than interpreters, who were available in house or by telephone. “The floors didn’t realize that they weren’t providing appropriate language services when they were using a family member, and that was one of the biggest issues,” she says.
Interpreter Services and Clinical Outcomes
One of the goals of the Robert Wood Johnson Foundation’s Speaking Together project was to find out whether there was a correlation between use of interpreter services and improved clinical outcomes.
Hennepin County Medical Center (HCMC), one of two Minnesota hospitals taking part, set out to measure whether use of language interpreters increased depression screening rates. The other Minnesota hospital, Regions Hospital, wanted to find out whether using interpreters had an effect on diabetic patient readmissions within 30 days of discharge.
HCMC found that it had been screening nearly all of its psychiatry patients for depression so there was little room for improvement. Regions found no correlation between use of interpreters and diabetic patient readmissions because its study sample was too small.
Marsha Regenstein, Ph.D., director of Speaking Together and an associate professor at George Washington University in Washington, D.C., says those findings didn’t surprise her. She notes that most of the hospitals that took part in the study found it difficult to isolate the effects of interpreter use. For example, hospitals that chose to assess the effect of interpreter use on patients’ hemoglobin A1c level, for example, found it difficult to control for the other variables that affect blood sugar levels.
“It’s just not realistic to believe that language services would move such a measure because providing a language service is not an additional service in terms of controlling blood sugar levels,” she says.—S.D.S.
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Van Dyke says that when Regions researched why this was the case, it found that the nurses weren’t aware of the available interpreter services and how to access them. Some also reported having trouble getting an interpreter—even by telephone—on the weekends or after hours. Van Dyke says Regions decided to address the problem in two ways: by educating nurses and by changing the way interpreters worked.
The hospital gave nurses a script they could use to decline a family member’s offer to interpret without offending them. “A vast majority of the time the family member is relieved because they have done their duty of being helpful and have been let off the hook,” Van Dyke says. Other educational efforts included telling nurses about the location and availability of special dual-handset phones that allow patients and clinicians to speak directly to each other through a telephonic interpreter. Van Dyke says they also labeled the speaker function on the phones to encourage their use during family conferences.
Perhaps the most significant change was having interpreters do rounds on the floors rather than wait for a call from a nurse or physician requesting their services. Regions added a function to its electronic health record that enables staff to create patient rosters based on their language preference. Every day, interpreters get a list of the patients on the units who speak Somali, Spanish, Hmong, or other languages.
During their daily rounds, the interpreters visit patients, ask about their language preference, and explain to them that interpreter services are available. About half of the visits lead to on-the-spot interpreting sessions, according to staff reports. In some cases, the interpreters learned that patients who nurses assumed did not need an interpreter actually preferred having one. In others, patients didn’t need an interpreter for most encounters but wanted one during visits with their doctor.
Van Dyke says interpreter rounding increases the interpreters’ contact with nurses and allows the nurses to become familiar with the services being offered. It also helps with scheduling, as nurses can take interpreter availability into consideration with scheduling a discharge.
By November of 2007, the educational campaign and the increased presence of interpreters were paying off. The units went from infrequent use of professional interpreters at admission and discharge to having one at both 70 percent of the time.
Van Dyke says, however, that barriers remain. For example, Regions is still struggling to get some providers to use the telephonic interpreter service. In addition, the hospital is trying to find ways to provide 24-hour access to interpreters, since nurses still report difficulty finding an interpreter either in the hospital or by telephone on weekends or after hours.
Redefining Roles
When HCMC’s 90-bed inpatient psychiatry unit first assessed its performance with regard to use of interpreters during admission and discharge of Somali patients last June, it found it was using interpreters only 25 percent of the time, according to Joanne Hall, R.N., director of psychiatric and rehabilitation services. Instead of interpreters, bilingual Somali nurses were doing the interpreting. Hall says this was disconcerting because they didn’t know the extent of nurses’ language skills. HCMC assesses its interpreters in order to ensure their proficiency. However, it did not assess the interpreting skills of bilingual medical staff.
Like Regions, HCMC started having an interpreter visit patients in the psychiatric unit every day. When it did a reassessment in February, the hospital found patients had interpreters at both admission and discharge 65 percent of the time.
In the diabetes clinic, the results weren’t as dramatic. Hall found that about 60 percent of Spanish-speaking patients had an interpreter during intake and discharge at the beginning of the study. By making interpreter availability a priority, the clinic increased the rate to 85 percent.
HCMC is now trying to better define the roles of bilingual providers and interpreters. It is devising a guide that will indicate which situations require an interpreter and which do not. The hospital is also planning on certifying its bilingual providers to ensure the quality of their interpreting.
Marsha Regenstein, Ph.D., director of the national Speaking Together project and an associate professor at George Washington University in Washington, D.C., which developed the national measures, is encouraged by the results of the collaborative. Like Regions and HCMC, many of the participating hospitals have been showing consistent improvement in their use of interpreters. “Hospitals are really trying to address language services. But in general, there is an enormous need for more and better services,” she says. MM
Scott Smith is an MMA staff writer.